‘A significant loss of expertise’ – campaign to reverse ‘steep decline’ in school nurses
A campaign for a school nurse in every school has been launched in a bid to reverse a ‘steep decline’ that has seen a 33% fall in the number of school nurses since 2009. A new report–based on a recent roundtable discussion–sets out the significant barriers that exist and offers some potential solutions
The figures are stark: The number of qualified school nurses has fallen by 33% in the last 13 years from 1 135 to 852 – many of whom it is feared will no longer be practising in schools.
Likewise, the number of NHS professionals working in school nursing (including the qualified school nurses listed above) has fallen by almost 1 000 – from 2 915 to 1 945.
A new report has laid bare the impact of this ‘significant loss of expertise, knowledge and skill’ that we have seen between September 2009 and December 2022.
The figures (NHS, 2023) show that the number of qualified school nurses first fell below 1 000 in 2019 and has been in decline ever since.
And the figures also hide ‘great variation’ across England with children and young people facing a postcode lottery of provision ‘with very serious consequences for families and for child health’. It warns that in some local authority areas, school nursing is no longer commissioned at all. Furthermore, the report emphasises that many of the 852 school nurses listed in the data ‘will no longer be practising as such’.
The report is based on a roundtable discussion held in December between nursing leaders, charities and NHS and government representatives and hosted by the Queen's Nursing Institute (QNI), the College of Medicine, and the School and Public Health Nurses Association (SAPHNA).
The report's message is clear: ‘Current services are insufficient to meet need. School nursing roles and services have been eroded in recent years and in many instances, resources are now insufficient to deliver the government's National Healthy Child Programme.’
Identifying the problems
The report cites ‘a reduced focus’ on funding for services for children and young people, warning that ‘school nursing has become depleted resulting in school nurses feeling overwhelmed and unable to deliver all elements of their role’.
It adds: ‘This then leads to a cycle of recruitment and retention challenges.’
The report explains: ‘School nurses are skilled and qualified professionals, educated to postgraduate level, whose practice is informed by a biopsychosocial perspective and grounded in prevention.
‘The roundtable heard it was a role which traditionally involved considering the broad range of biological, psychological and social factors, and intervening appropriately to support not only children and young people but their wider families. Increasingly, however, roles do not offer opportunities to use these skills.’
One participant described the job now as ‘firefighting and plugging gaps’. Another spoke of school nurses often working ‘solely as safeguarding nurses – not public health professionals’.
While acknowledging the ‘crucial’ role school nurses play in safeguarding, the report warns that a ‘disproportionate amount of school nurse time is often focused at the child protection and child in need end of the continuum’.
‘The risk is that their involvement is bureaucratic rather than beneficial to improving outcomes for the child. The change in the focus of the role means that it is difficult to retain experienced staff, who may be disillusioned by an inability to use the full range of their skills.’
It continues: ‘The risk is that their involvement is bureaucratic rather than beneficial to improving outcomes for the child. The change in the focus of the role means that it is difficult to retain experienced staff, who may be disillusioned by an inability to use the full range of their skills. It also makes the role less attractive to prospective nurses. This is a key factor in understanding the crisis not only in children's health but also in the school nursing workforce itself.’
Another consequence of the lack of school nurses is that ‘an increasing number’ of schools are now employing their own nurse. The report warns: ‘This is usually in response to the reduced visibility of school nurses from the local authority. However, these schoolemployed nurses tend not to be qualified school nurses and are often professionally isolated, which can be problematic.’
In particular, the report pinpoints the Health and Social Care Act 2012, which transferred responsibility for many public health services, including school nursing, from the NHS to local government at a time when funding for local authorities was being cut back severely due to austerity.
A lack of national oversight is also a problem, participants at the roundtable heard: ‘There is no central government oversight, so it is not possible to state with certainty how many school nurses are in place and in which areas, or to comprehensively know where services have been increased or decreased,’ the report adds.
Identifying the solutions
The roundtable recognised the importance of building political will, clarifying the role and responsibilities of school nurses, and improving school nurse workforce data to better understand how their work has an impact on outcome measures.
Ultimately, the roundtable said that a ‘coalition of support for school nursing’ had to be built – not least encouraging Integrated Care Boards to prioritise school nursing within healthcare strategies for children and young people in their areas. And there is hope, because – as was reported at the roundtable – from November 2023 the chief nursing officer has taken over professional leadership of public health nursing meaning that school nursing will be part of their forthcoming strategy. Furthermore, NHS long-term workforce plan has set out an ambition to increase school nurses by 48% – although as the participants pointed out this relates to training places, not funded roles.
Changes to how school nurse roles are commissioned could also prove fruitful, the discussion heard, with one case study from Tower Hamlets in east London having seen GP surgeries forming a social enterprise that commissions additional service including school nurses.
The report adds: Local authority representatives at the roundtable spoke of a desire to be braver in commissioning decisions. There was some optimism that the new NHS provider selection regime could ultimately help support this. These new procurement rules have an express aim of supporting collaboration across systems, increasing flexibility in processes, and ensuring all decisions are made in the best interests of service users.’
Participants also want to see more elements of the government's flagship 5 to 19 Healthy Child Programme mandated for delivery by school nurses.
The report adds: ‘The need to see school nursing as one key resource within a system, and to have it be part of an integrated approach, was highlighted. Considering how school nurses can fit in as part of the broader system, and how to capitalise on and complement the resources already present through initiatives like social prescribing, could be a valuable way of reinforcing the roles.
‘Where pots of money are available for new projects, such as mental health support teams, there would be real value in considering how school nurses could provide such services. Rather than reinventing the wheel each time, those resources could be invested in school nursing.’
A School Nurse in Every School
SAPHNA, the QNI and the College of Medicine have now pledged to work together to begin a campaign for a school nurse in every school. In 2021, the College of Medicine included the goal in its Hope for the Future manifesto and Dr Michael Dixon – who chaired the roundtable – said the discussion and report were ‘an important step’ in achieving this.
He added: ‘Participants pledged to move into action to help ensure school nursing is prioritised with investment in this highly skilled workforce.’
Speaking to CHHE after the roundtable, Sharon White, CEO of SAPHNA, pointed to a ‘horrifying downward trajectory’ in children's health, including re-emergence of diseases such as rickets, scurvy and malnutrition and rises in vaping and sexually transmitted diseases amid other challenges.
She said: ‘We know that this workforce is a crucial part of the solution and it is no coincidence that after over a decade of disinvestment aligned to the Treasury's Public Health Grant cuts, and an around 35% loss in staffing, we find ourselves in this dire situation.
‘As leaders of the Healthy Child Programme who are public health nurse specialists, expert at promotion, prevention and protection, there is no one better placed to help our children and young people repair, recover and restore.’
Sallyann Sutton, SAPHNA's interim professional officer, said that the Healthy Child Programme ‘cannot effectively be delivered’ because school nurses have declined to such an extent.
She added: ‘The result is sketchy delivery, a postcode lottery and an exhausted workforce. Our children and young people deserve better. They must have access to this universal reach – personalised in response, promotion, prevention and early intervention programme. It was humbling to have so many strategic partners at the table committing to ensuring every child and young person has access to a qualified school nurse.’
Dr Crystal Oldman, chief executive of the QNI, added: ‘School nursing services have been allowed to atrophy since they were transferred to cash-starved local authorities. We urgently need to invest in school nursing services that have a proven positive impact on the physical, mental and emotional health of children and young people at a crucial time in their lives.’
The roundtable and report have been funded by Sanofi but without input into the subjects that were discussed. To download the report, A School Nurse in Every School (2024), visit https://tinyurl.com/2jb4p34z
- NHS England: Workforce Statistics, 2023: https://tinyurl.com/2p9x8hdv
Attendance crisis: Schools call for more mental health support as parental disputes increase
School leaders fear a breaking down of the social contract between home and school with one-third seeing students kept home by angry parents and two-thirds reporting students who are too anxious to attend
Increasingly strained relationships with families are affecting school attendance, with school leaders concerned about the number of parental disputes they are seeing.
Survey findings published by the Association of School and College Leaders (ASCL) at its recent annual conference in Liverpool revealed some disturbing reasons for student absence.
One-third (32%) of the 8 411 teachers and school leaders responding to the research said that they have seen students missing school because of a dispute with their parents or carers. This figure rises to 48% among headteacher respondents to the survey.
The research asked what reasons parents/carers gave for student absence other than illness and found that term-time holidays is most common (87% rising to 95% among headteachers), ahead of family events (76% rising to 88%).
And 51% of the respondents, including 64% of the headteachers, also reported that students had been kept home because they were too tired from an event the previous evening.
Worryingly, 66% (rising to 76% of headteachers) said that students were simply too anxious to attend school emphasising just how much of a problem emotionally based school avoidance has become since the pandemic.
There is emerging evidence that parental attitudes to school have altered since the pandemic. A report by the think tank Public First last year warned that Covid had caused a ‘seismic shift’ in parental attitudes to attendance due in part to a ‘fundamental breakdown’ in the relationship between schools and parents (Burtonshaw & Dorrell, 2023).
The study says that term-time holidays have become ‘socially acceptable’ while school attendance systems feel ‘increasingly draconian’ to families. It states: ‘Sanctions are seen as both irrelevant and antagonistic across all parent groups.’
It also warns of the huge rise in mental health problems for young people which it says is ‘compounding issues around attendance’.
Incoming ASCL president John Camp used his address to the conference to call for a ‘change of tone’ in the national conversation about education. He raised his fears about the deterioration of the unwritten ‘social contract’ between families and schools.
He told delegates: ‘This is a hugely complex issue. But what I find alarming is those reasons which suggest absence from school may not be seen in the way it used to. And in particular it is surprising that some children are kept at home because of a dispute with the school.
‘This is an extreme – but apparently common – example of the fracturing of that unwritten social contract.’
He called for ‘tangible solutions’ to the attendance crisis, including greater investment in mental health support for children who are suffering from anxiety and depression and attendance support services which can identify what is going wrong and work directly with families.
The latest attendance figures show that persistent absence in the autumn term 2023 improved year-on-year but is still running at 20.1% – rising to 24.6% at secondary level.
For his part, Mr Camp also wants to see a change in the way politicians and the media talk about schools.
He said: ‘I think something else is also needed. And that is a change of tone in the national conversation about education. An acknowledgement that everybody in public life must do more to talk up the many good things about schools and colleges, and to talk about teaching as the noble profession it is.
‘It often seems like some politicians and commentators are far too quick to take potshots at schools. Potshots that are often based on confused perceptions, political agendas, and which are generally misplaced.
‘If politicians and commentators are constantly running down teachers and schools, and giving the impression that we can't be trusted, then they're helping to create a division.
‘I don't, of course, think that this – on its own – is the reason for that fracturing of the social contract. But it certainly doesn't help. It creates a febrile climate. And when social media is added into the mix, things can get very nasty very quickly. As I am sure many of us have experienced.
‘There will always be a robust debate about any education system. But we really do need for that debate to be more positive and less corrosive.’
- Burtonshaw & Dorrell: Listening to, and learning from, parents in the attendance crisis, Public First, 2023: http://tinyurl.com/2p9zjp6z
Absence thresholds: New £80 fines will hit disadvantaged students hardest
Students in years 9 and 10, disadvantaged young people, and those with SEN are among the groups most likely to receive the new and increased £80 fines for persistent absence, an analysis has revealed
If new government thresholds for absence had been implemented in 2022/23, the parents of 1 in 5 students would have received fixed penalty notices.
A national framework for parental fines is being introduced from September with increased fines of £80 for any student who misses 10 or more unauthorised half-days within any 10-week period.
An analysis based on attendance data from almost 10 000 schools (Bibby & Thomson, 2024) considered the number of students who would have broken this new threshold in 2022/23.
The results vary. While 15% of primary pupils broke the threshold in years 3 to 6, the proportion steadily increases from year 7 until it peaks in years 9 and 10 at around 23%.
And many students broke the threshold more than once with year 9 (13%) and year 10 (14%) once again having the worst figures.
But it is when you factor in SEN and disadvantage that the picture of just who will be getting fined becomes stark.
When it comes to students on free school meals, more than 40% of disadvantaged year 10 pupils would have been fined in 2022/23 compared to 16% of their non-disadvantaged peers. The figures are similar for year 9.
The same story is told for students with SEN: around 34% of year 10 students would have been fined compared to just over 20% of their non-SEN peers.
The analysts warn that their figures are likely to be an underestimate as the data is for 2022/23 alone and doesn't consider any 10-week periods that overlap with previous or subsequent academic years.
The DfE said that its new national framework will ‘tackle inconsistencies’ in the use of fines across the country.
The framework will be introduced from September when the Working together to improve school attendance guidance will become statutory.
The new rules still give schools and local authorities discretion, although while this means fines might not be issued in every case, it also means fines can be issued even before the new threshold is met.
The guidance requires that schools take ‘a support-first approach to help pupils and their families to tackle barriers to attendance’. Expectations include regular meetings between schools and local authorities to agree plans for the most atrisk absent children.
The DfE adds: ‘It particularly emphasises the importance of support for pupils with SEND and mental illhealth who often need more individual consideration due to wider barriers.
‘It asks schools, local authorities and wider services to work together to support these pupils, encouraging early intervention and close working with families to address their individual needs.’
Also under the new guidance, all state schools in England will be required to share their daily attendance registers.
The DfE wants this information to form a ‘new world-leading attendance dataset’ which it says will help schools and others to identify absence trends.
Schools, trusts and councils will be able to access this data via an ‘interactive secure data dashboard’ which is to be maintained by the DfE. However, it should be said that most schools already share their attendance data.
Geoff Barton, general secretary of the Association of School and College Leaders, said that parental fines ‘predominately relate to pupils who are taken out of school for term-time holidays’ but warned of a wider issue related to mental health and disengagement from education.
He explained: ‘There is a wider issue about absence relating to the growing number of children who suffer from anxiety and other mental health issues, families who are struggling to cope, and disengagement with education, which schools are endeavouring to address by working with families and pupils to improve their attendance rather than using fines.
‘Schools need more help from the government in this work both in terms of the funding they receive and investment in local social care, attendance and mental health services. Education has become an unofficial fourth emergency service picking up the pieces for a decade-long erosion of support services.’
- DfE: Guidance: Working together to improve school attendance, 2024: https://tinyurl.com/mfze3he2
- Bibby & Thomson: How many pupils are at risk of falling below the proposed new thresholds for attendance? FFT Education Datalab, 2024: https://tinyurl.com/wcn8vjrf
The lost 10 000 students: Are they safe? Are they in education? We don't know…
In the space of a year, more than 10 000 children left state education to destinations that are unknown to their local authorities – many because of ‘flimsy’ data-sharing practices.
In response to requests from the Office of the Children's Commissioner for England, local authorities were unable to say if these young people were safe or whether they were in education.
A further 13 120 students left state education and moved into home education – more than 80% of whom were persistent or severe absentees from school. These young people were also disproportionately more likely to have SEN or be living in poverty.
The figures cover the period spring 2022 to spring 2023 and have been laid out in a new report from children's commissioner Dame Rachel de Souza.
The report warns that an estimated 2 868 children have left state education and are now considered ‘a child missing education’ – again they are more likely to come from deprived areas and be known to social care.
The research is based on analysis of data from local authorities in England, administrative data held by the Department for Education, and discussions with local authorities and home-educating parents.
Children covered by the report were aged 4 to 14 at the start of the 2021/22 academic year, were present in the 2021/22 administrative data, recorded as living in an English local authority, but not present in the 2022/23 administrative data – and so had ‘appeared to have dropped off school rolls’.
The report outlines a number of recommendations to help improve the situation, including more oversight powers for local authorities as well as concerted action to improve school attendance, mental health, and SEND support.
A key finding is that better data-sharing and a more ‘comprehensive approach to children's data’ is required – this is borne out by the fact that 22% of the children identified in the report's data collection appeared to have left the state education system yet were later identified as being in state-funded mainstream schools. They had simply been – as the report's title implies – lost in transition.
Destination unknown
During the period in question, 10 181 children left state education to unknown destinations and a third of these young people had a history of persistent of severe absenteeism.
In 70% of cases, while the children were known to the local authority, there was no information about where they had gone. In 30% of cases the child was not even known to the local authority.
The report states: ‘Our report exposes the gaping holes in local authority data arrangements. Local authorities rely too heavily on individual relationships and goodwill to learn about the destinations of children who leave their schools. Despite the growing number of children leaving schools, the data-sharing practices in place are flimsy and not fit-for-purpose.’
The report unearths a particular problem at transition at age 10. One-fifth of the unknown destination children in the report were aged 10 because this is the point of transition to secondary school and pupils are getting lost in the system as information is not being shared.
Of the remaining unknown destination children, 54% were aged 4 to 9 and 25% were aged 11 to 14.
Children whose destinations are unknown were more likely to be disadvantaged and from an ethnic group other than white.
Home education
There are worrying trends highlighted in the report about the characteristics of home-educated students. They were:
- Much more likely to have had poor attendance with 82% having been either persistently or severely absent.
- More likely to be living in disadvantaged areas with 64% living in the more deprived half of neighbourhoods.
- Disproportionately likely to have identified SEN – 25% of children had SEN Support, more than double the average for state schools.
Indeed, many parents interviewed for the research said that their decision to home educate was influenced by ‘shortcomings in support for children with SEND’.
The report states: ‘Most parents … said that they had chosen home education as a last resort. Parents detailed a series of incidents where schools had not offered the support their child needed to engage in education. Often, their child had started to not attend school regularly or had been subject to a series of sanctions in school.’
Parents also ‘commonly mentioned’ a lack of support for children's mental health and anxiety.
The report adds: ‘Many parents and local authorities also told us about the challenges children face in trying to secure appropriate SEND provision. (We) heard of some instances where parents and schools disagreed over whether the child had a SEN and the level of support that would be necessary to enable them to engage in education.’
In her foreword to the report, Dame Rachel adds: ‘My office heard that the number of children in home education has been growing steadily and that many parents opting for home education are not doing so through choice.’
Children missing education
An estimated 2 868 children left the state education system and became a ‘child missing education’, meaning they were not registered at a school or otherwise receiving an education. The report adds: ‘Local authorities speculated that some of these children may have left the UK, but lacked data-sharing arrangements to check whether this was the case.’
The analysis found that:
- Children known to social care were 7 times more likely to become a child missing education.
- Poor attendance was a precursor of becoming a child missing education: 62% were either persistently absent or severely absent.
- Nearly half (46%) of all children missing education were from the most deprived quarter of neighbourhoods.
Dame Rachel warns: ‘Local authorities told my office that they were worried about this group of children and did not have sufficient resources or powers to identify and support these children to return to school.’
Recommendations
The report calls for national action on school attendance, the quality of alternative provision, and to better support young people's mental health and SEND requirements.
It also says that better management of the year 6 to 7 transition process is needed, suggesting a ‘national transition protocol’ be put in place.
Crucially, the report calls for ‘powers to identify children wherever they are educated’. It adds: ‘Local authorities told the office about the difficulties they face tracking children and how this impacts their ability to identify and support children not receiving a suitable education.
‘Information-sharing when a child leaves a school roll does not happen automatically. Schools must submit forms to the local authority and complete data returns. All too often, these steps are missed, and children fall through the gaps.’
The government has long promised to introduce a register of children who are not in school and, commenting on the report, Paul Whiteman, the general secretary of the National Association of Head Teachers, said that this must be brought forward urgently.
He also warned that the impact of cuts to key services was taking its toll: ‘Many councils have reduced early support for families amid government cuts, while funding for children's mental health services and provision for children with SEND has failed to keep pace with demand. A lack of capacity in the essential services needed to support pupils' additional needs sometimes contributes to school absence and decisions to educate children at home.
‘What is needed is significant new investment in services like local attendance support teams, children's social care, mental health services and special needs provision, and real action to tackle the poverty which fuels issues in families lives and makes it harder for young people to flourish at school.’
- Children's Commissioner: Lost in transition? The destination of children who leave the state education system, 2024: www.childrenscommissioner.gov.uk/resource/lost-in-transition
Safeguarding: Mandatory child sexual abuse reporting sparks threshold concerns
A new legal requirement to report child sexual abuse has sparked concerns about raised thresholds for intervention if children's social services struggle to cope with increased safeguarding referrals
The Home Office has stated its intention to implement a legal requirement for ‘anyone in regulated activity relating to children in England, including teachers or healthcare professionals, to report it if they know a child is being sexually abused’.
The new measures are to be introduced as amendments to the Criminal Justice Bill, which is currently progressing through Parliament.
The new mandatory reporting rules could see anyone failing to report being barred from working with children and young people.
The proposed new rules also state that anyone who actively protects child sexual abusers – by intentionally blocking others from reporting or covering up a crime – could go to prison for 7 years.
The proposals are a response to a key recommendation from the recent Independent Inquiry into Child Sexual Abuse (IICSA).
The 7-year investigation heard evidence from more than 6 200 victims and survivors. It found that most victims and survivors first experienced sexual abuse at primary school age (67%); 52% also experienced other forms of abuse as well as sexual abuse, almost half of victims and survivors were abused by a family member, and 12% were abused by a teacher or member of educational staff.
The family home was where abuse happened most often, with schools being the second most frequently reported location.
However, the Home Office announcement has sparked a warning that wider police and children's social services must have the capacity to deal with potential increases in the numbers of referrals that the new duty could well create.
The National Association of Head Teachers has said that if sufficient funding is not in place, then the knock-on effect could be raised thresholds for intervention.
General secretary Paul Whiteman said: ‘School leaders take children's safety incredibly seriously and invest time and funding in training and resources to support efforts to tackle all forms of child sexual abuse. They already have a range of statutory duties when it comes to safeguarding and are frequently inspected against these. However, schools rely on a wide range of other services when reporting concerns. We are concerned about the current capacity of services like children's social care and the police to provide children with the help they need should mandatory reporting lead to an increase in referrals being made.
‘It's vital the government provides these services with sufficient funding to ensure they can cope with demand and are not forced to raise thresholds for intervention.’
Gabrielle Shaw, chief executive for the National Association for People Abused in Childhood said: ‘The introduction of mandatory reporting is a big step in the right direction, which must be implemented alongside an approach that prioritises the wellbeing of the child and ensures they have access to ongoing, specialist support. This will require investment in training requirements, wider supporting structures and effective tracking and review.’
Chair of the IICSA, Professor Alexis Jay, said: ‘I look forward to working with the home secretary on the detail of this as the bill progresses.’
Minister for victims and safeguarding Laura Farris added: ‘By bringing into force a mandatory duty to report child sexual abuse – the IICSA's principal recommendation – we are sending a clear message that children will never be let down whether in schools, sports settings or any supervised environment.’
Mandatory reporting is already in place for female genital mutilation (FGM) meaning that teachers ‘must personally report to the police cases where they discover that an act of FGM appears to have been carried out’ as set out in the statutory safeguarding guidance Keeping children safe in education.